The world’s most widely used medical diagnostic manual, The International Classification of Diseases (ICD-11), contains a new diagnosis suitable for porn addiction: Compulsive Sexual Behavior Disorder.

Misrepresentations and omissions

The Men’s Health articles featured Dr. Nicole Prause, a non-academic who’s extensive history of actively campaigning against porn-induced ED and porn addiction is well documented. Let’s begin with Prause’s string of misinformation and false assertions:

Most men watch porn, so the thought of missing out on actual sex because you watched too many X-rated videos is, understandably, a pretty terrifying prospect. We were a bit hesitant to use the experiences of just two men to generalize about a world full of men who watch porn, so we talked to a few sex researchers with Ph.D.s to get a few more details on whether your habit can cause serious problems with your sex life.

The verdict? There’s no scientific evidence that supports the idea of “porn-induced erectile dysfunction.”

“There are three laboratory studies that have shown sex film viewing is unrelated to erectile functioning,” said Nicole Prause, Ph.D., founder of Liberos, a sex research and biotechnology company in Los Angeles. (You can find those studies here, here, and here.)

“No study has ever linked the two,” she says. “The therapists are literally manufacturing the idea that these are connected in their patients.”

Um…it is patently false to claim that no study has linked porn use to sexual problems. In reality, there are now 26 studies linking porn use/porn addiction to sexual problems and lower arousal to sexual stimuli. It’s not just correlation studies: the first 5 studies in the list demonstrate causation, as participants eliminated porn use and healed chronic sexual dysfunctions. Put simply, porn-induced sexual problems exist because medical professionals asked young men to refrain from porn – and they healed chronic sexual problems (ED, Anorgasmia, delayed ejaculation, low sexual desire). Fact check anyone?

What about Prause’s claim concerning the 3 studies she cited:

“There are three laboratory studies that have shown sex film viewing is unrelated to erectile functioning.” (You can find those studies here, here, and here.)

First, none of the studies were “laboratory studies”, so ignore that claim. The first study listed actually supports the hypothesis that porn use causes sexual problems as 71% of the heavy porn users in the study had developed chronic sexual problems! This is another example of a journalist failing to fact-check, as journalists writing articles about pornography so often fail to do. The second and third papers (one wasn’t a study) on the list were roundly criticized in the peer-reviewed literature, with many questioning both findings and methodologies. Below we examine the 3 papers separately:

What sexual dysfunction do 38% of the remaining men have? The study doesn’t say, and the authors have ignored repeated requests for details. Two primary choices for male sexual dysfunction are ‘erectile dysfunction’ and ‘low libido’. It should be noted that the men were not asked about their erectile functioning without porn. This, if all their sexual activity involved masturbating to porn, and not sex with a partner, many might be unaware they had porn-induced ED. (For reasons known only to her, Prause chronically cites this paper as debunking the existence of porn-induced sexual dysfunctions.)

PAPER #2: Prause & Pfaus, 2015.

I provide the formal critique by Richard Isenberg, MD and a very extensive lay critique, followed by my comments and excerpts from the paper co-authored by US Navy doctors:

The reality behind Prause & Pfaus 2015: This wasn’t a study on men with ED. It wasn’t a study at all. Instead, Prause claimed to have gathered data from four of her earlier studies, none of which addressed erectile dysfunction. It’s disturbing that this paper by Nicole Prause and Jim Pfaus passed peer-review as the data in their paper did not match the data in the underlying four studies on which the paper claimed to be based. The discrepancies are not minor gaps, but gaping holes that cannot be plugged. In addition, the paper made several claims that were false or not supported by their data.

We begin with false claims made by both Nicole Prause and Jim Pfaus. Many journalists’ articles about this study claimed that porn use led to better erections, yet that’s not what the paper found. In recorded interviews, both Nicole Prause and Jim Pfaus falsely claimed that they had measured erections in the lab, and that the men who used porn had better erections. In the Jim Pfaus TV interview Pfaus states:

“We looked at the correlation of their ability to get an erection in the lab.”

“We found a liner correlation with the amount of porn they viewed at home, and the latencies which for example they get an erection is faster.”

In this radio interview Nicole Prause claimed that erections were measured in the lab. The exact quote from the show:

“The more people watch erotica at home they have stronger erectile responses in the lab, not reduced.”

Yet this paper did not assess erection quality in the lab or “speed of erections.” The paper only claimed to have asked guys to rate their “arousal” after briefly viewing porn (and it’s even not clear from the underlying papers that this simple self-report was asked of all subjects). In any case, an excerpt from the paper itself admitted that:

“No physiological genital response data were included to support men’s self-reported experience.”

In other words, no actual erections were tested or measured in the lab!

In a second unsupported claim, lead author Nicole Prause tweeted several times about the study, letting the world know that 280 subjects were involved, and that they had “no problems at home.” However, the four underlying studies contained only 234 male subjects, so “280” is way off.

A third unsupported claim: Dr. Isenberg’s Letter to the Editor (linked to above), which raised multiple substantive concerns highlighting the flaws in the Prause & Pfaus paper, wondered how it could be possible for Prause & Pfaus 2015 to have compared different subjects’ arousal levels when three different types of sexual stimuli were used in the 4 underlying studies. Two studies used a 3-minute film, one study used a 20-second film, and one study used still images. It’s well established that films are far more arousing than photos, so no legitimate research team would group these subjects together to make claims about their responses. What’s shocking is that in their paper Prause & Pfaus unaccountably claim that all 4 studies used sexual films:

“The VSS presented in the studies were all films.”

This statement is false, as clearly revealed in Prause’s own underlying studies. This is the first reason why Prause & Pfaus cannot claim that their paper assessed “arousal.” You must use the same stimulus for each subject to compare all subjects.

A fourth unsupported claim: Dr. Isenberg also asked how Prause & Pfaus 2015 could compare different subjects’ arousal levels when only 1 of the 4 underlying studies used a 1 to 9 scale. One used a 0 to 7 scale, one used a 1 to 7 scale, and one study did not report sexual arousal ratings. Once again Prause & Pfaus inexplicably claim that:

“Men were asked to indicate their level of “sexual arousal” ranging from 1 “not at all” to 9 “extremely.”

This statement, too, is false, as the underlying papers show. This is the second reason why Prause & Pfaus cannot claim that their paper assessed “arousal” ratings in men. A study must use the same rating scale for each subject to compare the subjects’ results. In summary, all the Prause-generated headlines about porn use improving erections or arousal, or anything else, are unwarranted.

Prause & Pfaus 2015 also claimed they found no relationship between erectile functioning scores and the amount of porn viewed in the last month. As Dr. Isenberg pointed out:

Even more disturbing is the total omission of statistical findings for the erectile function outcome measure. No statistical results whatsoever are provided. Instead the authors ask the reader to simply believe their unsubstantiated statement that there was no association between hours of pornography viewed and erectile function. Given the authors’ conflicting assertion that erectile function with a partner may actually be improved by viewing pornography the absence of statistical analysis is most egregious.

In the Prause & Pfaus response to the Dr. Isenberg critique, the authors once again failed to provide any data to support their “unsubstantiated statement.” As this analysis documents, the Prause & Pfaus response not only evades Dr. Isenberg’s legitimate concerns, it contains several new misrepresentations and several transparently false statements. Finally, a review of the literature I wrote with 7 Navy doctors commented on Prause & Pfaus 2015:

Our review also included two 2015 papers claiming that Internet pornography use is unrelated to rising sexual difficulties in young men. However, such claims appear to be premature on closer examination of these papers and related formal criticism. The first paper contains useful insights about the potential role of sexual conditioning in youthful ED [50]. However, this publication has come under criticism for various discrepancies, omissions and methodological flaws. For example, it provides no statistical results for the erectile function outcome measure in relation to Internet pornography use. Further, as a research physician pointed out in a formal critique of the paper, the paper’s authors, “have not provided the reader with sufficient information about the population studied or the statistical analyses to justify their conclusion” [51]. Additionally, the researchers investigated only hours of Internet pornography use in the last month. Yet studies on Internet pornography addiction have found that the variable of hours of Internet pornography use alone is widely unrelated to “problems in daily life”, scores on the SAST-R (Sexual Addiction Screening Test), and scores on the IATsex (an instrument that assesses addiction to online sexual activity) [52, 53, 54, 55, 56]. A better predictor is subjective sexual arousal ratings while watching Internet pornography (cue reactivity), an established correlate of addictive behavior in all addictions [52, 53, 54]. There is also increasing evidence that the amount of time spent on Internet video-gaming does not predict addictive behavior. “Addiction can only be assessed properly if motives, consequences and contextual characteristics of the behavior are also part of the assessment” [57]. Three other research teams, using various criteria for “hypersexuality” (other than hours of use), have strongly correlated it with sexual difficulties [15, 30, 31]. Taken together, this research suggests that rather than simply “hours of use”, multiple variables are highly relevant in assessment of pornography addiction/hypersexuality, and likely also highly relevant in assessing pornography-related sexual dysfunctions.

This review also highlighted the weakness in correlating only “current hours of use” to predict porn-induced sexual dysfunctions. The amount of porn currently viewed is just one of many variables involved in the development of porn-induced ED. These may include:

Ratio of masturbation to porn versus masturbation without porn

Ratio of sexual activity with a person versus masturbation to porn

Gaps in partnered sex (where one relies only on porn)

Virgin or not

Total hours of use

Years of use

Age started using porn voluntarily

Escalation to new genres

Development of porn-induced fetishes (from escalating to new genres of porn)

Level of novelty per session (i.e. compilation videos, multiple tabs)

Addiction-related brain changes or not

Presence of hypersexuality/porn addiction

The better way to research this phenomenon, is to remove the variable of internet porn use and observe the outcome, which was done in the case studies in which men removed internet porn use and healed. Such research reveals causation instead of fuzzy correlations open to conflicting interpretation. My site has documented a few thousand men who removed porn and recovered from chronic sexual dysfunctions.

As for the claim that Landripet & Štulhofer, 2015 found no relationships between porn use and sexual problems. This is not true, as documented in both this YBOP critique and the this review of the literature. Furthermore, Landripet & Štulhofer’s paper omitted three significant correlations they presented to a European conference (more below). Let’s start with the first of three paragraphs from our paper that addressed Landripet & Štulhofer, 2015:

A second paper reported little correlation between frequency of Internet pornography use in the last year and ED rates in sexually active men from Norway, Portugal and Croatia [6]. These authors, unlike those of the previous paper, acknowledge the high prevalence of ED in men 40 and under, and indeed found ED and low sexual desire rates as high as 31% and 37%, respectively. In contrast, pre-streaming Internet pornography research done in 2004 by one of the paper’s authors reported ED rates of only 5.8% in men 35–39 [58]. Yet, based on a statistical comparison, the authors conclude that Internet pornography use does not seem to be a significant risk factor for youthful ED. That seems overly definitive, given that the Portuguese men they surveyed reported the lowest rates of sexual dysfunction compared with Norwegians and Croatians, and only 40% of Portuguese reported using Internet pornography “from several times a week to daily”, as compared with the Norwegians, 57%, and Croatians, 59%. This paper has been formally criticized for failing to employ comprehensive models able to encompass both direct and indirect relationships between variables known or hypothesized to be at work [59]. Incidentally, in a related paper on problematic low sexual desire involving many of the same survey participants from Portugal, Croatia and Norway, the men were asked which of numerous factors they believed contributed to their problematic lack of sexual interest. Among other factors, approximately 11%–22% chose “I use too much pornography” and 16%–26% chose “I masturbate too often” [60]

As my co-authors, the Navy doctors, and I described, this paper found a rather important correlation: Only 40% of the Portuguese men used porn “frequently,” while the 60% of the Norwegians used porn “frequently.” The Portuguese men had far less sexual dysfunction than the Norwegians. With respect to the Croat subjects, Landripet & Štulhofer, 2015 acknowledge a statistically significant association between more frequent porn use and ED, but claim the effect size was small. However, this claim may be misleading according to an MD who is a skilled statistician and has authored many studies:

Analyzed a different way (Chi Squared), … moderate use (vs. infrequent use) increased the odds (the likelihood) of having ED by about 50% in this Croatian population. That sounds meaningful to me, although it is curious that the finding was only identified among Croats.

In addition, Landripet & Štulhofer 2015 omitted three significant correlations, which one of the authors presented to a European conference. He reported a significant correlation between erectile dysfunction and “preference for certain pornographic genres”:

It’s telling that Landripet & Štulhofer chose to omit this significant correlation between erectile dysfunction and preferences for specific genres of porn from their paper. It’s quite common for porn users to escalate into genres (or fetishes) that do not match their original sexual tastes, and to experience ED when these conditioned porn preferences do not match real sexual encounters. As we pointed out above, it’s very important to assess the multiple variables associated with porn use – not just hours in the last month or frequency in the last year.

Increased pornography use was slightly but significantly associated with decreased interest for partnered sex and more prevalent sexual dysfunction among women.

A significant correlation between greater porn use and decreased libido and more sexual dysfunction seems pretty important. Why didn’t Landripet & Štulhofer 2015 report that they found significant correlations between porn use and sexual dysfunction in women, as well as a few in men? And why haven’t these findings been reported in any of Štulhofer’s many studies arising from these same data sets? His teams seem very quick to publish data they claim debunks porn-induced ED, yet very slow to inform users about the negative sexual ramifications of porn use.

The study does not address possible moderators or mediators of the relationships studied nor is it able to determine causality. Increasingly, in research on pornography, attention is given to factors that may influence the magnitude or direction of the relationships studied (i.e., moderators) as well as the pathways through which such influence may come about (i.e., mediators). Future studies on pornography consumption and sexual difficulties may also benefit from an inclusion of such focuses.

Bottom line: All complex medical conditions involve multiple factors, which must be teased apart before far-reaching pronouncements in the press are appropriate. Landripet & Štulhofer’s statement that, “Pornography does not seem to be a significant risk factor for younger men’s desire, erectile, or orgasmic difficulties” goes too far, since it ignores all the other possible variables related to porn use that might be causing sexual performance problems in users, including escalation to specific genres, which they found, but omitted from the “Brief Communication.” Paragraphs 2 & 3 in our discussion of Landripet & Štulhofer, 2015:

Again, intervention studies would be the most instructive. However, with respect to correlation studies, it is likely that a complex set of variables needs to be investigated in order to elucidate the risk factors at work in unprecedented youthful sexual difficulties. First, it may be that low sexual desire, difficulty orgasming with a partner and erectile problems are part of the same spectrum of Internet pornography-related effects, and that all of these difficulties should be combined when investigating potentially illuminating correlations with Internet pornography use.

Second, although it is unclear exactly which combination of factors may best account for such difficulties, promising variables to investigate in combination with frequency of Internet pornography use might include (1) years of pornography-assisted versus pornography-free masturbation; (2) ratio of ejaculations with a partner to ejaculations with Internet pornography; (3) the presence of Internet pornography addiction/hypersexuality; (4) the number of years of streaming Internet pornography use; (5) at what age regular use of Internet pornography began and whether it began prior to puberty; (6) trend of increasing Internet pornography use; (7) escalation to more extreme genres of Internet pornography, and so forth.

A 500% – 1000% increase in youthful ED since 2010 cannot be explained away by the usual factors

Prior to the advent of free streaming porn (2006), cross-sectional studies and meta-analysis consistently reported erectile dysfunction rates of 2-5% in men under 40. Erectile dysfunction rates in 9 studies published since 2010 range from 14% to 35%, while rates for low libido (hypo-sexuality) range from 16% to 37%. Some studies involve teens and men 25 and under, while other studies involve men 40 and under. One of the most dramatic recent examples (2018) is a survey of ED in porn actors. Those under 30 had twice the rate of ED as the older ones (whose sexuality developed without access to highspeed Internet porn during adolescence). See Erectile Dysfunction Among Male Adult Entertainers: A Survey.

In short there has been a 500%-1000% increase in youthful ED rates in the last 10 years. What variable has changed in the last 15 years that could account for this astronomical rise? Before confidently claiming that today’s porn consumers have nothing to worry about from Internet porn use, researchers still need to account for the very recent, sharp rise in youthful ED and low sexual desire, the many studies linking porn use to sexual problem, the thousands of self reports and clinician reports of men healing ED by eliminating a single variable: porn.

In the Men’s Health article Kerner (who is an AASECT spokesman) twists and turns to avoid blaming porn, asserting that masturbation causes chronic ED in health young men:

Though there may not be a direct connection between watching porn and erectile dysfunction, there is an indirect one in that in certain cases masturbation can lead to erection issues. “In my clinical experience I do not find porn to be a direct cause of [erectile disorder, premature ejaculation, and delayed ejaculation]” explains Ian Kerner, Ph.D. and licensed psychotherapist and sexuality counselor.

Before Ian Kerner became the chair of public relations for AASECT, he had a different opinion on porn-induced sexual problems. See the following 2013 article by Kerner, which undercuts 2018 Kerner (Maybe by becoming AASECT’s official spokesperson he felt compelled to follow the company line.):

Easy access to internet porn and the sheer variety of novelty it contains have affected average guys who wouldn’t normally have a problem.

As a sex therapist and founder of Good in Bed, I’ve seen a sharp increase in men who suffer from a new syndrome I’ve dubbed “Sexual Attention Deficit Disorder,” or SADD. And the source of this problem is just a click away — too much internet porn.

Just as people with ADD are easily distracted, guys with SADD have become so accustomed to the high levels of visual novelty and stimulation that comes from internet porn that they’re unable to focus on real sex with a real woman. As a result, guys with SADD often find it difficult to maintain an erection during intercourse, or they experience delayed ejaculation and can only climax with manual or oral stimulation.

Bored in bed?

Men with SADD tend to find themselves getting bored or impatient during sex. They may be physiologically aroused and erect, but they’re not at peak mental arousal. Guys with SADD may also simply lack the mojo for real sex because they’re depleted from masturbation. They’re not running on a full tank, physically or mentally.

Believe it or not, I first became aware of SADD via the complaints of women who wondered why their guys couldn’t ejaculate (and were often faking it) or who noticed that their partners seemed disconnected or uninterested during sex. When I dug a little deeper, or talked to the guys themselves, I realized that these men were masturbating more than usual due to their easy access to internet porn. Sometimes, they were masturbating about the same as always, but hadn’t realized that their natural refractory period — the recovery time between erections — was increasing as they aged.

Don’t get me wrong, I’m a big fan of masturbation. It helps a guy blow off some steam and is like a 30-second spa day. But easy access to internet porn and the sheer variety of novelty it contains have affected average guys who wouldn’t normally have a problem. Because of this, these men have rewired their brains to crave the instant gratification of a porn-enabled orgasm. This means that they’re developing what’s clinically referred to as an idiosyncratic masturbatory style: They’ve accustomed themselves to an intense type of physical stimulation that’s not approximated during real sex. Their overall levels of sexual desire for their partners are down, and they need to fantasize during real sex in order to maintain a full erection.

Think you suffer from SADD? Here’s what to do…

What’s a guy with SADD to do?

First, give yourself a masturbation break. Save your mojo for your partner. If you’re single, decrease your frequency of masturbation. When you do masturbate, try using your non-dominant hand. For example, if you’re a righty, touch yourself with your left. You won’t be able to apply the same levels of physical intensity as you can with your dominant hand, so you won’t be as physically numbed to the sensations of intercourse.

Second, lay off the porn. When you masturbate, use your mind to create the pictures and try to recall single episodes of sex. Think of it as the difference between reading and watching TV. Use this opportunity to reconnect with your erotic history and your own catalog of sexy memories.

Increase the mental novelty with your partner: Share fantasies and experiment with role play. Before you have intercourse, get yourself to a point where you’re at peak physical and mental arousal. SADD doesn’t have to be sad for you or your partner. Step away from your computer and toward your bedroom, and you can put your attention back where it belongs — on your real sex life.

Gavin Evans may wish to update his article in Men’s Health… but I won’t hold my breath.